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Year : 2017  |  Volume : 9  |  Issue : 4  |  Page : 163-164
Empyema necessitans: An unexpected infectious presentation of multiple myeloma

Department of Internal Medicine, East Tennessee State University James H. Quillen College of Medicine, Johnson City, TN, USA

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Date of Web Publication12-Dec-2017

How to cite this article:
Kapila A, Moore CA, Krishnaswamy G, Bajaj K. Empyema necessitans: An unexpected infectious presentation of multiple myeloma. J Global Infect Dis 2017;9:163-4

How to cite this URL:
Kapila A, Moore CA, Krishnaswamy G, Bajaj K. Empyema necessitans: An unexpected infectious presentation of multiple myeloma. J Global Infect Dis [serial online] 2017 [cited 2022 Jun 26];9:163-4. Available from:


Empyema necessitans (EN) is a rare clinical entity in which a suppurative infection in the soft tissue forms due to a sinus tract between an empyema and the thoracic wall, usually in the setting of smoldering pneumonia or osteomyelitis.

[1] With the advent of antibiotics, Streptococcus pneumoniae is uncommon unless there is underlying immunosuppression.[2] Multiple myeloma, a neoplastic proliferation of plasma cells, causes immunosuppression and can present with atypical infections due to encapsulated bacteria such as S. pneumoniae. However, EN has never been reported in the setting of multiple myeloma. We describe the first case of S. pneumoniae EN in multiple myeloma.

A 41-year-old male with no significant medical history came to the emergency department with worsening right-sided chest swelling associated with fever, chills, night sweats, and weight loss, following sudden-onset rib pain 7–8 months prior. He denied recent travel, trauma, or infections. On presentation, he was febrile with erythema, tenderness, and induration over the right lateral chest and decreased air entry in the right lung base. Laboratories are notable for leukocytosis with normocytic anemia and thrombocytosis.

Computed tomography chest demonstrated destructive changes involving the right ribcage associated with a soft tissue mass extending to the right costophrenic angle and the right lower lobe pleuroparenchymal tissue consistent with empyema [Figure 1]. Aspiration of the soft tissue mass revealed S. pneumoniae. The bone survey demonstrated multiple lytic lesions. Biopsy of the seventh right rib revealed sheets of small-to-intermediate bi- and multi-nucleated plasma cells staining positive for CD 138, with lambda light chain monotypia. Immunoglobulin G (IgG) level was elevated; IgA and IgE levels were decreased. Bone marrow biopsy confirmed the diagnosis of multiple myeloma.
Figure 1: Computed tomography chest, without contrast. Extensive soft tissue thickening, inflammation, and gas within the right lateral chest wall extending from the ribcage into the right lower lobe pleuroparenchyma indicating empyema necessitans

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The abscess resolved following 4 weeks of outpatient intravenous antibiotics through the peripherally inserted vascular catheter. The patient underwent induction therapy with bortezomib, thalidomide, and dexamethasone for multiple myeloma and was lost to subsequent follow-up.

S. pneumoniae is the most common organism associated with multiple myeloma, a neoplastic proliferation of plasma cells producing a monoclonal gammopathy with related organ or tissue impairment (lytic bone lesions, hypercalcemia, normocytic anemia, or renal failure).[3],[4] Paraproteinemia may cause suppression of other IgG isotypes (such as IgA and IgM in our patient), decreased granulocyte adhesion, impaired leukocyte migration, and complement defect, all of which contribute to fulminant infections from encapsulated bacteria.[5] This patient developed S. pneumoniae EN from immunosuppression due to underlying multiple myeloma. Physicians should consider multiple myeloma in the differential for older patients with rare encapsulated bacterial infections, who also have symptoms of anemia, renal failure, hypercalcemia, or bone pain. Our case stresses the importance of pneumococcal vaccination in immunocompromised patients to prevent infection and reduce morbidity and mortality.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Mizell KN, Patterson KV, Carter JE. Empyema necessitatis due to methicillin-resistant Staphylococcus aureus: Case report and review of the literature. J Clin Microbiol 2008;46:3534-6.  Back to cited text no. 1
Freeman AF, Ben-Ami T, Schulman ST. Streptococcus pneumonia empyema necessitatis. J Infect Dis 2004;23:177-8.  Back to cited text no. 2
Wong A, Marrie TJ, Garg S, Kellner JD, Tyrrell GJ; SPAT Group. Increased risk of invasive pneumococcal disease in haematological and solid-organ malignancies. Epidemiol Infect 2010;138:1804-10.  Back to cited text no. 3
Swerdlow SH, Campo E, Pileri SA, Harris NL, Stein H, Siebert R, et al. The 2016 revision of the World Health Organization classification of lymphoid neoplasms. Blood 2016;127:2375-90.  Back to cited text no. 4
Broder S, Humphrey R, Durm M, Blackman M, Meade B, Goldman C, et al. Impaired synthesis of polyclonal (non-paraprotein) immunoglobulins by circulating lymphocytes from patients with multiple myeloma role of suppressor cells. N Engl J Med 1975;293:887-92.  Back to cited text no. 5

Correspondence Address:
Dr. Christine Ann Moore
1185 West Mountain View Road, Apartment 1509, Johnson City, TN 37604
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jgid.jgid_35_17

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2008 Journal of Global Infectious Diseases | Published by Wolters Kluwer - Medknow
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